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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3612_Библиотеки_им_академика_М_И_Перельмана
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Key Questions in CONGENITAL CARDIAC SURGERY
4 What are the key views for obtaining
echocardiographic images in congenital
transthoracic echocardiography?
Abdominal views, including:
•
a) short-axis situs view (Figure 3A);
b) long-axis of the abdominal aorta (Figure 3B);
c) long-axis of the inferior vena cava (Figure 3C).
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Figure 3. Abdominal views, with: A) short-axis situs view; B) long-axis of the
abdominal aorta; and C) long-axis of the inferior vena cava. IVC = inferior
vena cava; Ao = aorta; RA = right atrium; HV = hepatic vein.
Subcostal long-axis and short-axis views.
•
Apical four-chamber (Figure 4) and five-chamber (aorta is known as
•
the 5th chamber) views.
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Figure 4. Apical four-chamber view.
RA = right atrium; LA = left atrium; RV =
right ventricle; LV = left ventricle.
4 Congenital echocardiography
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Parasternal long-axis (Figure 5A) and short-axis (Figure 5B) views.
•
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Figure 5. Parasternal: A) long-axis and B) short-axis views. RA = right
atrium; LA = left atrium; RV = right ventricle; LV = left ventricle; Ao = aorta;
RVOT = right ventricular outflow tract; MPA = main pulmonary artery; LPA =
left pulmonary artery; RPA = right pulmonary artery; RCC = right coronary
cusp of the aortic valve; LCC = left coronary cusp of the aortic valve; NCC =
non-coronary cusp of the aortic valve.
Suprasternal long-axis aortic arch view (Figure 6).
•
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Figure 6. Suprasternal long-axis aortic arch
view. Ao = aorta.
Key Questions in CONGENITAL CARDIAC SURGERY
Left subclavicular view showing the ‘crab-view’ of the pulmonary
•
veins joining the left atrium (Figure 7).
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Figure 7. Left subclavicular view demonstrating the pulmonary veins
joining the left atrium. LUPV = left upper pulmonary vein; RUPV = right upper
pulmonary vein; LLPV = left lower pulmonary vein; RLPV = right lower
132
pulmonary vein.
5 When is three-dimensional imaging commonly used?
Modern machines may use specialised probes to obtain 3D
•
echocardiographic images and specific computer software to
process the image after acquisition.
3D echocardiographic images are commonly used to demonstrate
•
cardiac morphology, heart valves, septal structures or complex
lesions, in order to aid interventional or surgical planning.
3D echocardiographic assessment of cardiac function can be
•
helpful, but challenging for dilated ventricles or functionally single
ventricles, and functional analysis should be interpreted with caution
in patients with abnormal anatomy.
Live 3D echo is particularly helpful to guide interventions, such as
•
device closure of septal defects.
6 What is the Z-score?
The Z-score is the number of standard deviations (SD) of a
•
measurement from the mean.
A measurement 2 SD above the mean will have a Z-score of +2
•
(97.7th percentile), whereas a Z-score of -2 indicates the
measurement is 2 SD below the mean (2.3rd percentile).
4 Congenital echocardiography
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Measurements of all cardiac structures can be undertaken with
•
subsequent application of Z-scores relative to the patient’s body
surface area.
7 What are the characteristics of an atrial septal defect
on echocardiography?
Patent foramen ovale (PFO) — which can usually be best seen as a
•
small communication in the central portion of the atrial septum on the
subcostal view (Figure 8). They are usually <4mm in size. In usual
situs solitus, blood flow from the left atrium to the right is red on
colour Doppler, whilst blood flow in the opposite direction from the
right to left atrium appears blue on TTE (colours are reversed on
TOE). In adults, a PFO may be difficult to see on TTE and a bubble
contrast echocardiogram may be required for detection.
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Figure 8. Subcostal images demonstrating a: A) patent foramen ovale
(PFO, red arrow); and B) left-to right blood flow on the corresponding
colour flow Doppler image. RA = right atrium; LA = left atrium; RV = right
ventricle; LV = left ventricle.
Secundum ASD — which can be seen as a communication in the
•
central portion of the atrial septum on the subcostal view (Figure 9).
In large defects, the rims of the defect should be ascertained utilising
multiple views to assess suitability for transcatheter device closure.
Primum ASD — which can be seen as a defect at the junction of the
•
primum atrial septum and atrioventricular valves on the subcostal and
apical views (Figure 10). An absence of the usual offsetting of the
tricuspid and mitral valves is noted, as instead of the tricuspid valve septal
attachment normally being slightly lower than the mitral valve, in primum
ASD, the right and left atrioventricular valves are at the same level.
134
Key Questions in CONGENITAL CARDIAC SURGERY
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Figure 9. Subcostal images with colour flow Doppler demonstrating a: A)
secundum atrial septal defect (blue arrow); and B) fenestrated atrial septal
defect with two defects (white crosses). RA = right atrium; LA = left atrium.
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Figure 10. Subcostal view demonstrating a: A) primum atrial septal
defect (green asterisk); and B) left to right blood flow across the defect
(white arrow) on the corresponding colour flow Doppler image. RA = right
atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.
Superior sinus venosus defect — which can be seen as a defect in
•
close proximity to the pulmonary veins and superior vena cava on a
high right parasternal view.
4 Congenital echocardiography
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Coronary sinus defect — which can be seen as a defect secondary
•
to unroofing of coronary sinus tissue on the subcostal view.
Right atrial and right ventricular dilatation associated with secondary
•
volume overload may also be seen and are best assessed from the
apical four-chamber view. This view, however, is inadequate to
assess the ASD size, as the ultrasound beam is perpendicular to the
defect causing dropout of the image that may lead to an overestimation of size.
The rims of the ASD are determined on multiple views, including:
•
a) subcostal four-chamber view — to assess the rim towards the
SVC junction and towards the atrioventricular valves;
b) subcostal short-axis view — to assess the SVC and IVC
junctions with the RA;
c) parasternal short-axis view — to assess the anterior-posterior
relationship from the aortic root and especially the adequacy of
the aortic rim;
d) high right parasternal view — to assess a sinus venosus
defect, with the probe in the superior-inferior orientation.
135
8 What are the principles of assessing a patent ductus
arteriosus on echocardiography?
Echocardiographic assessment is best obtained from the
•
suprasternal notch and left subclavicular views.
It should include demonstration of the haemodynamic features that
•
would influence whether the patent ductus arteriosus (PDA) is
haemodynamically significant, and the important details to plan
successful surgical intervention, including the:
a) course and size of the PDA (Figure 11);
b) velocity and direction of the shunt, utilising both Doppler
assessment of blood flow and colour flow Doppler;
c) estimation of the pulmonary artery pressure, using the peak
systolic velocity; also measuring simultaneous non-invasive
systolic blood pressure at the time of the echocardiographic
measurement;
d) left atrial and ventricular size (which will be dilated in the
presence of a significant PDA), and left ventricular function;
e) arch-sidedness and branching pattern of the head and neck
vessels;
f) presence of coarctation or hypoplasia;
g) presence of branch pulmonary artery stenosis.
136
Key Questions in CONGENITAL CARDIAC SURGERY
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Figure 11. A) 2D image of a paraternal short-axis view showing a dilated
main pulmonary artery (MPA) dividing in a fork-like appearance into a
right and left pulmonary artery (RPA; LPA) and a patent ductus arteriosus
(PDA). B) Corresponding colour image showing red flow in the PDA passing
from the aorta into the pulmonary artery. C) Doppler showing continuous
left to right flow in the PDA.
9 What are the principles of assessing a ventricular
septal defect on echocardiography?
Echocardiography is used to determine the position, borders, size
•
and number of ventricular septal defects (VSDs).
Perimembranous VSDs (Figure 12) are best assessed in the short-
•
axis view where the fibrous continuity is noted between the aortic and
tricuspid valves. It is important to delineate any muscular extension
and the margins of the VSD, which can be achieved by sweeps of
the septum in the parasternal and apical views. The subcostal views
may be useful in neonates and infants. Evidence of aortic valve
incompetence should also be ascertained.
Muscular VSDs (Figure 13) are best assessed by a short-axis sweep
•
of the ventricular septum and a posterior to anterior sweep of the
4 Congenital echocardiography
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Figure 12. Echocardiographic images demonstrating a large
perimembranous ventricular septal defect (*) on: A) apical four-chamber
view; B) corresponding colour flow Doppler image; C) parasternal short-axis
view (where the green arrow represents the VSD and the red arrow the
aortic-tricuspid valve continuity); and D) corresponding colour flow Doppler
image. RA = right atrium; LA = left atrium; RV = right ventricle; LV = left
ventricle. Ao = aorta; PA = pulmonary artery; TV = tricuspid valve.
septum in the apical view. The whole septum should be assessed
with a low Nyquist limit (colour scale). These VSDs may be small,
large or multiple throughout the ventricular septum.
Doubly-committed subarterial VSD (Figure 14) is best assessed in
•
the subcostal short-axis view, where a fibrous continuity between the
aortic and pulmonary valves can be seen. Evidence of aortic or
pulmonary valve incompetence should also be ascertained.
When echocardiography is performed on a patient with a VSD, there
•
are a number of features that should be assessed, including the:
137
a) whole interventricular septum, to ensure that all defects are
identified, as this will influence the operative approach;
138
Key Questions in CONGENITAL CARDIAC SURGERY
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Figure 13. Echocardiographic images demonstrating multiple
muscular ventricular septal defects (arrows) on the: A) apical fourchamber view; and B) corresponding colour flow Doppler image. RA =
right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.
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Figure 14. Echocardiographic image demonstrating a
doubly-committed subarterial ventricular septal defect
(*) with evidence of continuity (red line) between the
aortic and pulmonary valves. Ao = aorta; PA =
pulmonary artery.
4 Congenital echocardiography
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b) degree of ventricular volume overload and function;
c) septal attachment of the tricuspid valve and evidence of valve
straddling;
d) aortic valve for evidence of regurgitation;
e) right ventricular outflow tract muscle bundles.
Postoperatively, following VSD repair, it is important to assess the:
•
a) repair and identify any evidence of patch leak;
b) left ventricular function;
c) tricuspid valve function and identify regurgitation;
d) Doppler gradient across the pulmonary artery, if the patient has
undergone banding.
10 What are the principles of assessing aortic valve
disease on echocardiography?
The best views to assess obstruction of the left ventricular outflow
•
tract include the:
139
a) parasternal long-axis (Figure 15) — which can determine the
length of the outflow tract, the presence of any muscular tissue
or membrane at subaortic and supra-aortic levels, as well as
motion and thickness of the aortic valve leaflets, including cusp
prolapse and lack of coaptation. Colour flow Doppler in this
view may identify the presence of aortic valve regurgitation;
b) parasternal short-axis — which can determine the number of
aortic valve cusps and any abnormalities in functionality of the
valve, including the presence of a raphe. Colour flow Doppler
in this view may identify areas of regurgitation secondary to
poor coaptation of the valve leaflets. The short-axis view at the
level of the ventricle can also show any associated left
ventricular hypertrophy (Figure 16);
c) apical five-chamber and subcostal short-axis — which can
determine the length of the left ventricular outflow tract. Colour
flow Doppler in this view is particularly useful in showing areas
of turbulent flow and regurgitation, as it provides an
appropriate angulation for Doppler interrogation of the area.
Pulsed wave and continuous Doppler (Figure 17) can also be used
•
to estimate the severity of stenosis. By aligning the left ventricular
outflow tract with the cursor and utilising Doppler, the peak velocity
can be measured and the peak and mean pressure gradients can be
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